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What Not to Do with a Shoulder Impingement Exercises?

Last Updated on November 4, 2025 by mcelik

What Not to Do with a Shoulder Impingement Exercises
What Not to Do with a Shoulder Impingement Exercises? 4

Nearly 1 in 5 adults will experience shoulder pain at some point in their lives. Shoulder impingement syndrome is a common cause of this pain.

This condition happens when the tendons of the shoulder joint get irritated or inflamed. It causes a lot of pain and limits how well you can move. It’s important to know what activities and exercises to avoid to manage symptoms and help your shoulder heal.

We will look at the common mistakes people with an impinged shoulder make. We’ll also talk about how to avoid these mistakes to prevent more irritation and injury.

Key Takeaways

  • Avoid heavy lifting and bending
  • Steer clear of exercises that exacerbate the condition
  • Maintain good posture to reduce strain
  • Be cautious with overhead activities
  • Modify daily activities to minimize shoulder stress

Understanding Shoulder Impingement Syndrome

What Not to Do with a Shoulder Impingement Exercises
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It’s important to understand shoulder impingement syndrome to manage and recover well. This condition happens when the rotator cuff tendons get inflamed or irritated. This usually happens from doing the same motion over and over or from bad posture.

What causes shoulder impingement?

Several things can lead to shoulder impingement syndrome. These include:

  • Repetitive Overhead Activities: Sports like swimming, tennis, or baseball, and jobs that require frequent overhead reaching can lead to impingement.
  • Poor Posture: Forward head posture or rounded shoulders can reduce the space between the acromion and the rotator cuff tendons, causing irritation.
  • Anatomical Variations: Some individuals may have a naturally hooked or curved acromion, increasing the risk of impingement.

Common symptoms to recognize

Spotting the symptoms of shoulder impingement syndrome early is key to getting the right treatment. Common signs include:

  1. Pain when lifting the arm or doing overhead activities.
  2. Aching or stiffness in the shoulder, often at night or after activity.
  3. Weakness in the shoulder or trouble rotating the arm.

Understanding the impact of shoulder impingement on daily life can empower individuals to make necessary adjustments for relief.

Shoulder impingement syndrome can make everyday tasks hard. For example:

  • Dressing: Putting on or taking off clothes can hurt.
  • Sleeping: Finding a comfy sleeping spot is tough because of shoulder pain.
  • Reaching: Doing overhead tasks, like getting things from high shelves, can make symptoms worse.

Understanding the impact of shoulder impingement on daily life can empower individuals to make necessary adjustments for relief.

The Anatomy of an Impinged Shoulder

What Not to Do with a Shoulder Impingement Exercises
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The shoulder’s complex anatomy is key to understanding impingement. Shoulder impingement exercises affects the rotator cuff tendons and the subacromial space. This is where the tendons pass under the acromion, a bony part of the shoulder blade.

Structures Involved in Shoulder Impingement

The shoulder joint, also known as the glenohumeral joint, is made up of bones, tendons, and ligaments. The rotator cuff, a group of muscles and tendons, surrounds the joint. It provides stability and helps with movement. When the rotator cuff tendons rub against the acromion or other structures, they can become inflamed or irritated, leading to impingement.

Types of Shoulder Impingement: Subacromial vs. Internal

There are two main types of shoulder impingement: subacromial and internal. Subacromial impingement happens when the rotator cuff tendons inflame or irritate as they pass under the acromion. This is the most common type. Internal impingement occurs when the tendons of the rotator cuff rub against the posterior-superior glenoid or surrounding soft tissues.

Type of ImpingementDescriptionCommon Causes
Subacromial ImpingementTendons inflamed or irritated under the acromionRepetitive overhead movements, poor posture
Internal ImpingementTendons come into contact with posterior-superior glenoidThrowing motions, swimming, repetitive lifting

Risk Factors for Developing Impingement Syndrome

Several factors can lead to shoulder impingement syndrome. These include repetitive overhead movements, poor posture, and muscle imbalances. People who do sports or activities that involve throwing, lifting, or overhead motions are at higher risk. Also, those with poor posture or jobs that require repetitive shoulder movements are more likely to get it.

Knowing these risk factors can help prevent shoulder impingement. By avoiding activities and postures that contribute to the condition, individuals can reduce their risk.

Why Proper Treatment Matters

Understanding the impact of shoulder impingement on daily life can empower individuals to make necessary adjustments for relief.

Potential Complications of Untreated Impingement

Not treating shoulder impingement can lead to many issues. These include ongoing pain, more damage to tendons, and even rotator cuff tears. Chronic inflammation and pain can really lower someone’s quality of life.

Long-term Effects on Shoulder Function

Ignoring shoulder impingement can harm shoulder function over time. It can reduce how far you can move your shoulder and how strong it is. This can make everyday tasks and sports harder.

Impact on Quality of Life and Athletic Performance

Shoulder impingement, if not treated right, can really affect your life and sports performance. The pain and stiffness can stop you from doing sports and daily activities.

“Pain is a signal that something is wrong, and ignoring it can lead to more severe problems.”

ComplicationsLong-term EffectsImpact on Life and Performance
Persistent painReduced range of motionHinders daily activities
Further tendon injuryDecreased strengthAffects athletic performance
Rotator cuff tearsChronic inflammationReduces quality of life

Dangerous Movements to Avoid

To manage shoulder impingement well, it’s important to know which movements to stay away from. Some activities can make the condition worse, leading to more pain and less ability to move.

Overhead Activities That Worsen Impingement

Overhead activities are a big problem for shoulder impingement. This includes lifting heavy things above your head, doing overhead throws, or playing sports like swimming or tennis without warming up right.

  • Lifting heavy objects overhead
  • Overhead throwing motions
  • Swimming strokes that involve overhead movements

Avoiding these activities or changing them can help lessen the pressure on your shoulder.

Repetitive Motions That Cause Inflammation

Repetitive motions, like lifting, throwing, or reaching, can cause a lot of inflammation in the shoulder. Examples include:

  1. Repetitive lifting of heavy objects
  2. Continuous overhead work
  3. Assembly line work involving repetitive arm movements

Lowering how often you do these motions or taking breaks can help avoid inflammation.

Daily Activities That Put Stress on the Shoulder

Even everyday tasks can stress the shoulder if not done right. Examples include:

ActivityStressful MovementModification
Reaching for high shelvesLifting arms overheadUse a step stool
Carrying heavy bagsStraining shoulder musclesDistribute weight evenly
Sleeping on the affected sideCompressing the shoulderSleep on the opposite side

By being careful with these daily tasks and making small changes, you can lessen the stress on your shoulders.

In conclusion, it’s key to avoid harmful movements to manage shoulder impingement. Knowing which activities to avoid and how to adjust them can help prevent irritation and aid in healing.

Shoulder Impingement Exercises to Avoid

Exercise can help or hurt when you have shoulder impingement. It’s key to know which exercises help and which make things worse.

High-Risk Strength Training Exercises

Some strength training can stress the shoulder too much, making symptoms worse. Heavy lifting or overhead moves are risky.

  • Overhead Press: This can irritate the tendons and bursae around the shoulder joint.
  • Bench Press: It can cause the shoulder to roll forward, irritating an impinged shoulder.
  • Upright Row: Shrugging up towards the ears can compress the structures under the acromion.
ExerciseRisk LevelAlternative
Overhead PressHighLateral Raises (lower weight)
Bench PressModerateIncline Dumbbell Press
Upright RowHighFace Pulls

Problematic Stretching Techniques

Some stretches can make shoulder impingement worse. It’s important to avoid stretches that cause pain or discomfort.

  • Cross-Body Stretch: This can compress the tendons against the acromion, worsening impingement.
  • Behind-the-Back Stretch: Stretching this way can irritate the rotator cuff tendons.

Sports-Specific Movements that Aggravate Symptoms

Athletes need to be careful with throwing, overhead moves, or heavy lifting. These can irritate the structures involved in shoulder impingement.

  • Overhead Serving in Tennis or Volleyball: This motion can repetitively irritate the shoulder tendons.
  • Throwing in Baseball: The force and speed of throwing can make impingement symptoms worse.

Knowing which exercises to avoid can help manage shoulder impingement. This can reduce symptoms and aid in recovery.

Weight Training Mistakes with an Impinged Shoulder

When you have an impinged shoulder, it’s important to change your weight training. Some exercises can make the shoulder worse. We’ll look at common mistakes and how to make your routine better for your shoulder.

Bench Press Modifications and Alternatives

The bench press is a key exercise, but it can be hard on the shoulder. It involves lifting a weight over your chest, which can hurt the tendons and bursae. To make it safer, try a narrower grip or adjust the bench’s incline.

Instead of the bench press, try dumbbell presses or cable presses. These exercises are easier on the shoulder because they allow for a more natural motion.

Overhead Press Concerns and Safer Options

The overhead press can be tough for people with shoulder impingement. It lifts weight straight over the shoulder, which can press on the tendons. To lessen the risk, use a neutral grip or try a landmine press.

For safer alternatives, try lateral raises or front raises. These exercises work the deltoids without the overhead motion. They help keep the shoulder strong without making the impingement worse.

Pull-up and Lat Pulldown Considerations

Pull-ups and lat pulldowns are great for the back and arms, but they can be hard on the shoulder. The pulling motion can irritate the impinged area. To make these exercises safer, focus on proper form and use a resistance band to lighten the load.

For lat pulldowns, use a wider or neutral grip handle. This can reduce shoulder strain. Also, avoid heavy weights and use slow, controlled movements to lower the risk of irritation.

Incorrect Posture and Movement Patterns

Poor posture and bad movement patterns often cause shoulder pain. These habits can make shoulder impingement worse. It’s important to avoid them.

How Poor Posture Contributes to Impingement

Poor posture can put the shoulder joint in a bad spot. This can press on the tendons, causing pain. Maintaining good posture helps avoid this and aids in healing.

Bad posture also makes muscles work too hard. This can lead to muscle fatigue and tendon irritation. It makes shoulder impingement symptoms worse.

Movement Compensations that Worsen Symptoms

Movement changes can also hurt the shoulder. When we’re in pain, we might move differently. But this can strain other parts of the shoulder, making pain worse.

For example, avoiding using a hurt arm or changing how we lift can help short-term. But it can cause long-term problems like muscle imbalances. Correcting these faulty movement patterns is key to getting better.

Correcting Faulty Mechanics During Daily Activities

Being mindful of how we do daily tasks is important. Small changes, like adjusting your computer monitor or stretching, can help a lot.

  • Pay attention to your posture, keeping your spine straight and avoiding slouching.
  • Make your workspace better for your shoulders, like using an ergonomic chair or adjusting your keyboard and mouse.
  • Do exercises that strengthen your shoulder muscles. This improves stability and lowers injury risk.

Understanding how posture and movement habits affect the shoulder helps us take action. By fixing these issues, we can recover faster and prevent future problems. This keeps our shoulders healthy for the long term.

Self-Treatment Errors to Avoid

When dealing with shoulder impingement, it’s important to avoid certain mistakes. These mistakes can make the condition worse. Knowing these common errors can help you make better choices for your care.

Inappropriate Use of Ice and Heat

Using ice and heat incorrectly is a common mistake. Ice helps reduce inflammation early on, while heat increases blood flow and relaxes muscles later. Using ice too long or too often can make tissues stiff. Applying heat too early can increase inflammation.

To use ice and heat right, follow a structured plan. For acute injuries, ice should be applied for 15-20 minutes, several times a day, for the first 48-72 hours. After that, or for chronic conditions, use heat to relax muscles and reduce stiffness. Always wrap ice or heat packs in a towel to avoid burns or frostbite.

Over-reliance on Pain Medications

Another mistake is relying too much on pain medications. These can provide temporary relief but don’t fix the underlying issue. Using too many pain medications can lead to side effects and dependency.

It’s important to use pain medications wisely and with a doctor’s guidance. Instead of just taking medication, try gentle exercises, stretching, and lifestyle changes to tackle the root cause of your symptoms.

Aggressive Self-Mobilization Techniques

Using aggressive self-mobilization techniques is another error. While some exercises are good, too much or the wrong kind can irritate the shoulder and make symptoms worse.

It’s safer and more effective to use gentle, controlled movements. Learn these from a qualified healthcare professional, like a physical therapist. They can give you personalized advice based on your specific situation. This way, you can do exercises correctly and safely, without risking further injury.

The Problem with “Pushing Through Pain”

It’s important to understand pain’s role in shoulder impingement for safe healing. Pain is not just a bother; it’s a warning that something is wrong in our body.

Why pain is a protective mechanism

Pain is a protective signal, warning us of harm or injury. With shoulder impingement, pain tells us to avoid certain movements to prevent damage. Ignoring pain can cause more harm and slow healing. We must see pain as a natural protector.

The body’s pain response is complex, involving many pathways and signals. Pain is a sign our body is trying to protect us. For example, shoulder impingement pain from lifting your arm means you should stop to avoid making it worse.

Distinguishing between therapeutic discomfort and harmful pain

It’s key to tell the difference between exercise discomfort and harmful pain. Therapeutic discomfort is a dull ache that goes away after stopping. Harmful pain is sharp, lasts long, and may come with swelling or numbness.

  • Therapeutic discomfort: A manageable ache during or after exercise that doesn’t last long.
  • Harmful pain: Sharp, severe, or persistent pain that indicates possible damage.

Setting appropriate activity boundaries

Finding the right balance between activity and rest is key for shoulder impingement recovery. This means avoiding activities that make it worse while keeping up with safe exercises. We should work with healthcare pros to create a plan that respects our limits.

To set proper activity limits, consider these steps:

  1. Watch your pain levels before, during, and after activities.
  2. Stay away from or change activities that make pain worse.
  3. Slowly increase safe activity intensity and time.

By understanding pain’s role, knowing the difference between safe and harmful pain, and setting limits, we can better handle shoulder impingement. This approach helps in recovery and keeps our shoulders healthy in the long run.

Safe and Effective Shoulder Impingement Exercises

Gentle and targeted exercises can help a lot with shoulder impingement recovery. It’s key to pick exercises that help heal without making things worse. We’ll look at exercises that are safe and work well for shoulder impingement.

Gentle Mobility Exercises for Early Recovery

In the early recovery stages, gentle exercises are key. They help get your range of motion back and reduce stiffness. Make sure to do these exercises without pain to avoid making things worse.

  • Pendulum Exercise: Lean forward, letting your affected arm hang down. Gently swing your arm in small circles.
  • Wall Slide: Stand with your back against a wall and slide your arm up the wall, keeping it straight.
  • Cross-Body Stretch: Gently pull your affected arm across your body with your other arm.

Progressive Strengthening Techniques

As you get better, adding strengthening exercises can help. Start with low weights and slowly increase them.

  1. Resistance Band Exercises: Use resistance bands to perform external rotations and abductions.
  2. Light Dumbbell Exercises: Perform shoulder flexion and abduction with light dumbbells.

It’s essential to listen to your body and stop if you experience pain.

Scapular Stabilization Exercises

Strengthening the muscles around the scapula is important for shoulder health. It helps prevent future impingement.

  • Scapular Squeeze: Sit or stand with your arms at your sides and squeeze your shoulder blades together.
  • Wall Push-Ups: Perform push-ups against a wall to engage your scapular stabilizers.

Adding these exercises to your routine can help keep your shoulders healthy. It also lowers the chance of future impingement. Always talk to a healthcare professional before starting any new exercise program.

Alternative Exercise Options During Recovery

Staying active while your shoulder heals is doable with the right exercises. It’s important not to stop moving completely. This can harm your health and make recovery take longer. Luckily, there are many exercises that keep you fit without hurting your shoulder.

Lower Body Training that Spares the Shoulder

Working out your lower body is a great way to stay strong and fit without stressing your shoulder. Here are some good exercises:

  • Squats: Works your legs, glutes, and hamstrings.
  • Lunges: Targets your legs and can be adjusted for your fitness level.
  • Leg Press: Strengthens your legs without using your shoulder.
  • Calf Raises: Builds calf muscle strength, with or without equipment.

These exercises boost your lower body strength and overall fitness. They also help with recovery by improving blood flow.

Cardiovascular Exercise Modifications

Keeping your heart healthy with cardio exercises is key. But, you should modify these to avoid shoulder strain during recovery. Here are some options:

  • Cycling: Stationary cycling is easy on your shoulder.
  • Elliptical Trainer: Offers a full-body workout with little shoulder impact.
  • Swimming: Choose strokes that don’t stress your shoulder, like leg-driven ones.
  • Walking: A gentle activity that’s easy on your shoulder.

These cardio exercises keep your heart healthy and endurance up without hurting your shoulder.

ExerciseImpact on ShoulderBenefits
CyclingLowImproves cardiovascular fitness, leg strength
Elliptical TrainerLowFull-body workout, low impact
SwimmingVariable (depends on stroke)Full-body workout, low impact
WalkingLowImproves cardiovascular fitness, easy on joints

Core Training with Minimal Shoulder Involvement

Keeping your core strong is important for stability. You can do this during shoulder recovery with the right exercises. Here are some good ones:

  • Plank: Works your core without straining your shoulder.
  • Bridges: Targets your glutes and lower back.
  • Russian twists: Use lighter weights to avoid shoulder strain.
  • Leg raises: Strengthens your lower abs.

Staying strong in your core supports your fitness and helps prevent injuries. It also helps stabilize your body.

“The key to successful recovery from shoulder impingement is finding a balance between rest and maintaining overall fitness. By incorporating lower body, cardiovascular, and core exercises, individuals can stay active while allowing their shoulder to heal.” -Physical Therapy Expert

Professional Treatment Approaches

When you have shoulder impingement, getting professional help is key. Professional treatment approaches can really help. They can make you feel better and help you get back to doing things you love.

We suggest a treatment plan that includes many steps. Physical therapy is a big part of this.

Physical Therapy Interventions

Physical therapy is very important for shoulder impingement. Personalized exercise programs help improve shoulder movement. They also make the muscles stronger and help move better.

Our physical therapists create a plan just for you. They focus on what you need and what you want to achieve.

Some common physical therapy steps for shoulder impingement include:

  • Range of motion exercises to improve flexibility
  • Strengthening exercises to target the rotator cuff and scapular stabilizers
  • Manual therapy techniques to enhance joint mobility and reduce pain

Manual Therapy Techniques

Manual therapy is a big part of physical therapy for shoulder impingement. Manual therapy techniques like joint mobilization and soft tissue mobilization help. They reduce pain, improve joint movement, and help healing.

Medical Treatments: Injections, Medications, and Surgical Options

Medical treatments might be needed for shoulder impingement. Corticosteroid injections can cut down inflammation and pain. Pain relievers and anti-inflammatory drugs might also be given. Sometimes, surgery like arthroscopic subacromial decompression is needed.

We help decide the best treatment plan for you. We consider your specific needs and situation.

Lifestyle Modifications for Shoulder Health

Making simple changes to our daily habits can significantly improve shoulder health. By adjusting our lifestyle, we can alleviate discomfort, prevent further irritation, and promote overall well-being.

Sleeping Positions for Shoulder Comfort

The way we sleep can significantly impact our shoulder health. Sleeping on the affected side can make the condition worse. Sleeping on the back or unaffected side can help ease pressure. We recommend using a supportive pillow to maintain proper spinal alignment and reduce strain on the shoulder.

  • Sleep on your back with a pillow under your knees to take pressure off your spine and shoulders.
  • Use a supportive pillow to maintain proper neck alignment and reduce strain on your shoulders.
  • Avoid sleeping on the affected side to prevent further irritation.

Workplace Ergonomic Adjustments

Making ergonomic adjustments at work can help reduce the risk of shoulder impingement. Ensuring our workspace is set up to promote good posture and reduce strain on the shoulders is key.

  1. Position your computer monitor directly in front of you, at a distance of about 20-25 inches.
  2. Adjust your chair height to maintain proper posture, with your feet flat on the floor or on a footrest.
  3. Keep your keyboard and mouse close to your body to avoid reaching forward.

Activity Modifications for Daily Tasks

Modifying our daily activities can help alleviate shoulder discomfort and prevent further irritation. By making simple changes, we can reduce the strain on our shoulders and promote overall health.

  • Avoid heavy lifting or bending, which can exacerbate shoulder impingement.
  • Take regular breaks to stretch and move around, reducing the risk of repetitive strain.
  • Use assistive devices, such as a cart or trolley, to reduce the strain on your shoulders when lifting or carrying heavy objects.

By implementing these lifestyle modifications, we can significantly improve our shoulder health and reduce the risk of further irritation. It’s essential to be mindful of our daily habits and make adjustments to promote overall well-being.

Preventing Recurrence After Recovery

To avoid shoulder impingement coming back, you need to take care of your shoulder. After getting better, keep your shoulder healthy with exercises, changing how you do activities, and watching for early signs of trouble.

Maintenance Exercises for Long-Term Shoulder Health

Keeping your shoulder strong is key. Maintenance exercises help by strengthening muscles, improving flexibility, and stabilizing the scapula. Here are some examples:

  • Scapular squeezes to strengthen the muscles between the shoulder blades
  • Arm circles to improve flexibility and range of motion
  • Resistance band exercises to strengthen the rotator cuff muscles

Do these exercises 2-3 times a week. This keeps your shoulder muscles strong and ready for anything.

Activity Modifications to Protect the Shoulder

Changing how you do things is also important. Activity modifications help by reducing strain on your shoulders. For instance:

ActivityModification
Reaching overheadUse a step stool or ladder instead of stretching
Lifting objectsKeep objects close to your body and avoid twisting
Sleeping positionAvoid sleeping on the affected shoulder

Early Intervention Strategies for Recurring Symptoms

Sometimes, symptoms can come back. Early intervention is vital to stop it from getting worse. Know the early signs of shoulder impingement, like pain or less mobility, and act fast.

If symptoms come back, here’s what to do:

  1. Rest and modify activities to avoid making it worse
  2. Apply ice or heat as needed to manage pain and inflammation
  3. Do gentle exercises to keep flexibility and strength
  4. See a healthcare professional for advice and treatment

By being proactive and following these steps, you can lower the chance of shoulder impingement coming back. This helps keep your shoulder healthy for a long time.

Conclusion: Building Long-Term Shoulder Health

Managing shoulder impingement well is key to keeping your shoulders healthy for a long time. Knowing what causes it, its symptoms, and how to treat it is a big step towards getting better. We’ve talked about how to avoid making things worse, like some exercises and daily tasks.

Understanding the impact of shoulder impingement on daily life can empower individuals to make necessary adjustments for relief.

By following the advice in this article, you can work towards keeping your shoulders healthy for a long time. This means being dedicated to caring for your shoulders and managing shoulder impingement well. This way, you can avoid it coming back.

FAQ

What is shoulder impingement syndrome?

Shoulder impingement syndrome happens when the rotator cuff tendons get inflamed or irritated. This often occurs due to repetitive motion or poor posture.

What are the common symptoms of shoulder impingement?

Symptoms include pain when lifting the arm or doing overhead activities. You might also notice reduced mobility and discomfort in the shoulder joint.

What activities should I avoid with shoulder impingement?

Stay away from overhead activities and repetitive motions. Also, avoid daily tasks that stress the shoulder joint to prevent further irritation and injury.

Are there specific exercises I should avoid with shoulder impingement?

Yes, avoid high-risk strength training exercises and problematic stretching techniques. Also, sports-specific movements that aggravate symptoms should be avoided.

Can I stil workout with shoulder impingement?

Yes, but modify your workout to avoid making the condition worse. Focus on lower body training and cardiovascular exercises. Also, do core training with minimal shoulder involvement.

How can I manage shoulder impingement pain?

Remember, pain is a protective mechanism. Avoid “pushing through pain.” Use ice and heat therapy for pain management. Always consult with a healthcare professional.

What are some safe exercises for shoulder impingement?

Gentle mobility exercises and progressive strengthening techniques are safe. Scapular stabilization exercises also help in recovery and promote shoulder stability.

How can I prevent recurrence of shoulder impingement?

Perform maintenance exercises and modify activities to protect the shoulder. Adopt early intervention strategies to maintain long-term shoulder health.

What lifestyle modifications can help alleviate shoulder impingement?

Adjust your sleeping position and make workplace ergonomic adjustments. Modify daily activities to reduce discomfort and prevent further irritation.

When should I seek professional treatment for shoulder impingement?

If symptoms persist or worsen, consult a healthcare professional. Professional treatment, including physical therapy and medical treatments, can provide relief and promote recovery.

What are the potentially complications of untreated shoulder impingement?

Untreated impingement can lead to chronic pain, reduced mobility, and decreased strength in the shoulder. This can impact your quality of life and athletic performance.

Can poor posture contribute to shoulder impingement?

Yes, poor posture can significantly contribute to shoulder impingement. Correcting faulty mechanics during daily activities is key to alleviating discomfort and promoting recovery.

References

  1. Escamilla, R. F., Yamashiro, K., Paulos, L., & Andrews, J. R. (2014). Optimal management of shoulder impingement syndrome. PMC – National Center for Biotechnology Information. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945046/ 

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